COSHOCTON COUNTY AUDITOR
CHRISTINE R. SYCKS
349 MAIN STREET
COSHOCTON, OH 43812
740-622-1243

CITY INCOME TAX LIABILITY

NAME:____________________________     S.S. NUMBER ______________

DATE OF BIRTH                     

RESIDENCE: (CHECK ONE)
                                        WITHIN COSHOCTON CORP LIMITS

                                        OUTSIDE CITY LIMITS 

PLACE OF WORK (CHECK ONE)
                                        WITHIN COSHOCTON CORP LIMITS

                                        OUTSIDE CITY LIMITS

DO YOU RESIDE IN A CITY WHERE YOU HAVE TO PAY ADDITIONAL CITY TAXES AND WOULD LIKE TO HAVE THEM WITHHELD FROM YOUR CHECK?
IF SO, PLEASE LIST THE CITY   ________________________________

DO YOU RESIDE IN A SCHOOL DISTRICT THAT REQUIRES A SCHOOL DISTRICT INCOME TAX TO BE WITHHELD?   
IF SO, NAME OF SCHOOL DISTRICT  ______________________________

______________________________                 __________________
SIGNATURE                                   DATE